MEDICARE: MAMATA KHANAL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	125065958	IL

General Provider Information

NPI Number	:	1760897623
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MAMATA KHANAL

Provider Business Mailing Address
First Line	:	1926 W HARRISON ST APT NO1400
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60612-3737
Country	:	US
Telephone Number	:	804-873-3741
Fax Number	:

Provider Business Practice Location Address
First Line	:	1926 W HARRISON ST APT NO1400
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60612-3737
Country	:	US
Telephone Number	:	804-873-3741
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/29/2014
Last Update Date	:	06/29/2014

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Directions to “ MAMATA KHANAL ” Practice Location

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